Form

This should be filled out by the patient or the patient's legal guardian!

If you're an adult patient or a patient's legal guardian, please continue.

If you're under the age of 18 and your parent or legal guardian is not available, do not continue. Please contact our office (717.738.0124) for further instructions.

Who is filling out this check-in?

Patient's First Name

Patient's Last Name

Patient's Date Of Birth

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Have you, the patient, or anyone with you, traveled overseas within the last 14 days?

Have you, the patient, or anyone with you, traveled within the USA by air, bus or train within the last 14 days?

Have you, the patient, or anyone with you, been tested for COVID-19 and are awaiting the results?

Have you, the patient, or any of your recent acquaintences tested positive for COVID-19 or any other diseases in the last 14 days?

Have you, the patient, come into contact with anyone experiencing symptoms of COVID-19 in the last 14 days?

Have you, the patient, or anyone with you, experienced a persistent cough in the last 14 days?

Have you, the patient, or anyone with you, experienced shortness of breath in the last 14 days?

Have you, the patient, or anyone with you, experienced chest pressure in the last 14 days?

Have you, the patient, or anyone with you, had a fever greater than 100.4 F in the last 14 days?

Do you have any chronic immune or systemic conditions?

CONSENT TO TREATMENT

As with any illness, anyone can be exposed to COVID-19 at any time or place. We have always followed all recommended guidelines, laws and disinfection protocols in our office. Even with our careful attention, the chance remains that you could be exposed in our office, just as you might be anywhere. We've taken significant measures to keep you safe, however, it's not always possible to maintain a constant distance between the patient, our office staff and sometimes other patients.

Patient/Legal Guardian Signature

Date